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7E2AF6ISC Workers Comp AffadavitANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? INSR ADD'LLTRINSRD DATE (MM/DD/YYYY) PRODUCER INSURED POLICY EFFECTIVE POLICY EXPIRATIONPOLICY NUMBER LIMITSDATE (MM/DD/YYYY)DATE (MM/DD/YYYY)TYPE OF INSURANCE GENERAL LIABILITY AUTOMOBILE LIABILITY GARAGE LIABILITY EXCESS / UMBRELLA LIABILITY WORKERS COMPENSATION AND EMPLOYERS' LIABILITY OTHER DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS AUTHORIZED REPRESENTATIVE INSURER A: INSURER B: INSURER C: INSURER D: INSURER E: EACH OCCURRENCE $ DAMAGE TO RENTEDCOMMERCIAL GENERAL LIABILITY $PREMISES (Ea occurrence) CLAIMS MADE OCCUR MED EXP (Any one person)$ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER:PRODUCTS - COMP/OP AGG $ PRO-POLICY LOCJECT COMBINED SINGLE LIMIT $(Ea accident)ANY AUTO ALL OWNED AUTOS BODILY INJURY $(Per person)SCHEDULED AUTOS HIRED AUTOS BODILY INJURY $(Per accident)NON-OWNED AUTOS PROPERTY DAMAGE $(Per accident) AUTO ONLY - EA ACCIDENT $ ANY AUTO EA ACC $OTHER THAN AUTO ONLY:AGG $ EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE $ RETENTION $$ WC STATU-OTH-TORY LIMITS ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ If yes, describe under E.L. DISEASE - POLICY LIMIT $SPECIAL PROVISIONS below Y / N (Mandatory in NH) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC # COVERAGES CERTIFICATE HOLDER CANCELLATION ACORD 25 (2009/01)© 1988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD CERTIFICATE OF LIABILITY INSURANCE THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER AND THE CERTIFICATE HOLDER. UMBRELLA FORM Lockton Companies, LLC-1 Kansas City 444 W. 47th Street, Suite 900 Kansas City MO 64112-1906 (816) 960-9000 INDUSTRIAL SERVICES COMPANY, INC. 3648 W. NICHOLS STREET SPRINGFIELD MO 65803 INDSE02 For questions regarding this certificate, contact the number listed in the 'Producer' section above and specify the client code 'INDSE02'. JI American Guarantee and Liab. Ins. Co.26247 Navigators Insurance Company 42307 Zurich American Insurance Company 16535 Catlin Specialty Insurance Company 15989 X X 1,000,000 300,000 10,000 1,000,000 2,000,000 2,000,000 X X X 1,000,000 XXXXXXX XXXXXXX XXXXXXX XXXXXXX XXXXXXX XXXXXXX X X 10,000,000 10,000,000 XXXXXXX XXXXXXX XXXXXXX X N 1,000,000 1,000,000 1,000,000 (C) LEASED/RENTED (C) BLDRS RISK (D) PROF/POLL (C) $350,000 PER ITEM (C) $10,000,000 PER JOB SITE (D) $5,000,000 PER CLAIM/AGG A BAP6724338 9/1/2010 9/1/2011 A GLO6724337 9/1/2010 9/1/2011 C (C) CH10ILM016606 9/1/2010 9/1/2011C(C) CH10ILM016607 9/1/2010 9/1/2011D(D) CPV1974680911 9/1/2010 9/1/2011 C CH10EXC714082IV 9/1/2010 9/1/2011 B WC6724336 9/1/2010 9/1/2011 NOT APPLICABLE 9/1/2011 1330160 11/4/2010 11051756 ECOLAB INC. 50 SQUARE DRIVE, SUITE 200 VICTOR NY 14564 RE: COCA-COLA NORTH AMERICA. CERTIFICATE HOLDER IS AN ADDITIONAL INSURED ON ALL LINES, EXCEPT WORKER’S COMPENSATION, IF REQUIRED BY WRITTEN CONTRACT. 30 X